Changes to coverage

The breadth (who), scope (what) and depth (how much) of public cover have all changed over the duration of the crisis.

Population entitlement

Statutory entitlements to publicly financed health care in Ireland are complex (Brick et al., 2010; Thomson, Jowett & Mladovsky, 2012), as described in IR Table 4. The most significant change reducing the breadth of cover was the abolition, in 2009, of the automatic entitlement to a medical card for those aged over 70. Nevertheless, more than half a million more people had medical cards in 2013 than in 2008, reflecting lower incomes and a significant extension of coverage during the crisis.

IR Table 4 Entitlement to publicly financed health care in Ireland, 2013 Type of care Category I

(medical card holders) Category II

(do not hold medical cards) GP visit card

GP services Free Pay full charge Free

Pharmaceuticals Pay €1.50 per prescription item up to €19.50 per month per family (General Medical Services Scheme)

Pay full cost up to €144 per month per family (Drugs Payment Scheme); free for

outpatient care Free Free emergency department

attendance with GP referral or pay €100 per visit without GP referral; free access to all other outpatient services

Source: Thomson, Jowett & Mladovsky, 2012.

Eligibility for category I (medical card holders) is primarily determined on the basis of an income means test. Individuals in category II, including GP visit card holders, have access to a range of public assistance schemes such as the Drugs Payment Scheme, the Long Term Illness Scheme and the Treatment Benefit Scheme (see Thomson, Jowett & Mladovsky (2012) for further details).

14 The impact of the financial crisis on the health system and health in Ireland

The share of the population in category I fell in the late 1990s because of the rapid economic growth, a steady decline in unemployment and annual increases in real incomes (IR Fig. 3). However, it has increased steadily since 2005 (along with the introduction of the GP visit card), and from 2008 with the onset of the severe and prolonged recession. In December 2012, 40.4% of the population had a medical card, with an additional 2.9% of the population holding a GP visit card.

IR Fig. 3 Population coverage by category in Ireland, 1990–2012

Note: Population data refer to April but coverage data refer to December.

Sources: HSE, 2011a, 2012c, 2013g; CSO, 2014b; also annual reports (various years) from the Primary Care Reimbursement Service and the General Medical Services Payment Board.

Many people in category II and a small proportion of those in category I purchase PHI, which is supported in public policy via generous tax relief. PHI cover increased steadily over time, reaching a peak of 51.4% of the population in 2006, but then declining to 46.0% in 2012⁵ and is declining at an increasing rate (Health Insurance Authority, 2013). Originally designed to offer cover for hospital care, several PHI plans now also offer some cover for GP and other primary care expenses. While everyone is entitled to public hospital care at a maximum cost of €800 per annum, individuals take out PHI in order to gain faster access into the public hospital system (Watson & Williams, 2001).

5 Figures calculated from the Health Insurance Authority (2012, 2013) and the CSO databank.

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Medical card GP visit card Category II

Population coverage (%)

15 The impact of the financial crisis on the health system and health in Ireland

Proposed changes to population coverage are part of wider government commitments to reform health financing in Ireland, as set out in the 2011 Programme for Government (Government of Ireland, 2011a). Under the banner of “universal health insurance”, entitlement to GP visit cards is to be extended to the whole population by 2015. Movement towards this goal began with the drafting of primary legislation to provide GP visit cards to those covered by certain illnesses (Dáil Éireann, 2012), but this aspect of the plan has since been dropped because of legislative difficulties (Cullen, 2013). An alternative mechanism for the extension of free GP care to the entire population is currently being developed, with suggestions that it will be extended on an age-related basis starting with children under 5 years of age.

Key targets in the phasing in of universal primary care have been missed. It is not clear how the Programme for Government proposals will change coverage in practice, partly because details of expanded coverage of other services have yet to be specified and partly because of the budgetary environment. Furthermore, the 2013 Budget announced plans to restrict eligibility to medical cards for 2013, specifically taking full medical cards away from 40 000 people and replacing them with GP visit cards (HSE, 2013b). Moreover, the HSE Service Plan allowed for a net increase of 60 000 full medical cards in 2013, considerably less than the approximately 160 000 full medical cards granted in 2012 (HSE, 2013d), highlighting that further rationing of medical cards would lie ahead.

One million medical card reviews were planned for 2014.

Between September 2013 and March 2014, 65 000 medical cards were withdrawn. This was a result of the increased standardization of eligibility criteria brought about by the centralizing of the medical card assessment service in 2012/2013, combined with reducing income limits and tighter conditions for eligibility, as well as better linking with other government data. There was huge public and political discontent, with a range of high-profile stories in the public domain of very sick people losing their medical cards. In response to this, combined with a very poor performance of government parties in local and European elections in May 2014, the government suspended reviews of all discretionary medical cards, the removal of which caused the most controversy.

They also committed to extending medical card access on the basis of need, not just financial hardship. An expert panel was established to advise government on how best to progress this issue by Autumn 2014.

The benefits package and user charges

The scope of cover has been reduced through the introduction of limits to dental and ophthalmic benefits for the whole population and the rationing of some services such as therapies and home help (IR Table 5). However, most of the changes have targeted the depth of cover by increasing user charges.

16 The impact of the financial crisis on the health system and health in Ireland

IR Table 5 Changes to statutory entitlement in Ireland, 2008–2013

Year Category I Category II (includes GP visit card)

2008 None All: increase in hospital emergency

department attendance charge (without a referral) to €66 (from €60); increase in the public hospital inpatient charge to €66 per day (from €60)

DPS: increase in monthly deductible to €90 (from €85)

2009 Automatic entitlement to medical cards removed from people over 70 years of age and replaced with a means test

All: increase in hospital emergency department attendance charge (without a referral letter) to €100 (from €66); increase in the public hospital inpatient charge to €75 per day

DPS: increase in monthly deductible to €100 Tax relief on unreimbursed medical expenses restricted to the standard rate of tax (20%) 2010 GMS: introduction of €0.50 charge

per prescription item (October) Dental Treatment Services Scheme:

dental entitlements cut (April)

DPS: increase in monthly deductible to €120 TBS: dental and ophthalmic entitlements cut

2011 None None

2012 None DPS: increase in monthly deductible to €132

TBS: aural entitlements cut

Long Term Illness Scheme: commitment to extend entitlement to free GP care as phase 1 of free primary care strategy (abandoned and due to be replaced with an alternative plan to extend free GP care to the entire population)^a

2013 GMS: increase to €1.50 in charge per prescription item

Lowering of thresholds for medical cards for the those over 70 years of age to exclude a further 40,000 people (April)

DPS: increase in monthly deductible to €144 Hospitals: increase in the public hospital inpatient charge to €80 per day

Notes: DPS: Drug Payment Scheme; GMS: General Medical Scheme; TBS: Treatment Benefit Scheme; unless otherwise stated, all measures came into force on 1 January of each year; ^aIn May 2013, it was reported that the government had encountered legal difficulties in drafting legislation to extend free GP care to those covered by the Long-term Illness Scheme (Cullen, 2013).

An alternative plan to extend free GP care to the entire population is currently being developed although no further details are available.

Sources: Thomson, Jowett & Mladovsky, 2012; HSE, 2013ab; Citizen's Information Board, 2014.

17 The impact of the financial crisis on the health system and health in Ireland

3.3 Changes to health service planning, purchasing